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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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8 Colon
Rectal cancer
Surgical choice • Local trans-anal excision can be considered for low rectal cancer <8cm from anal verge,
<3cm in size, <30% of rectal circumference, stage 0-I with favorable tumor grade
• Stage II and III: Will require 5cm proximal margin, distal margin 2–5cm (can <1cm if
sphincter preserving), 12 lymph nodes required
• Abdominoperineal resection: If sphincter muscles involved or if surgical margin will include
sphincter muscles or if patient has baseline incontinence
• Total Mesorectal excision: Concept that regardless of surgical approach, the entire mesorectal
fat and lymph node envelope should be excised with the specimen and should not be violated
intraoperatively. Greatly reduces risk of local recurrence
261
Follow-up
• Outpatient exam and CEA every 3–12 months for 2years➔every 6–12months for 3years
• CT chest, abdomen, and pelvis twice in 5years or up to annually for 5years
• Colonoscopy after 1year➔3years➔every 5years
Transanal excision of localized rectal cancer
Key steps Must be full thickness (should see perirectal fat intraoperatively)
>3mm margins
Complications and their
management
Bleeding, urinary retention (most common), recto-vaginal or recto-prostatic stula,
pelvic sepsis
Research about rectal cancer
Reference Findings
Hrebinko KA, etal. Transanal excision with adjuvant
therapy for pT1N0 rectal tumors with high-risk
features offers equivalent survival to radical resection:
A National Cancer Database analysis. J Surg Oncol.
2022;125(3):475–483. https://doi.org/10.1002/jso.26734.
Epub 2021 Oct 27. PMID: 34705273; PMCID:
PMC8961452
Bahadoer RR; RAPIDO collaborative investigators.
Short-course radiotherapy followed by chemotherapy
before total mesorectal excision (TME) versus
preoperative chemoradiotherapy, TME, and optional
adjuvant chemotherapy inlocally advanced rectal
cancer (RAPIDO): a randomised, open-label, phase 3
trial. Lancet Oncol. 2021;22(1):29–42. https://doi.
org/10.1016/S1470- 2045(20)30555- 6. Epub 2020 Dec 7.
Erratum in: Lancet Oncol. 2021 Feb;22(2):e42. PMID:
33301740
Transanal excision was non-inferior to trans-abdominal
approach for pT1N0 rectal adenocarcinoma with
high-risk features
Short course chemoradiotherapy followed by
chemotherapy and then surgery is a regimen that
achieves good local control while also preventing
distant failure compared to giving chemotherapy after
surgery
Garcia-Aguilar J, etal. Organ preservation in patients
with rectal adenocarcinoma treated with Total
neoadjuvant therapy. J Clin Oncol. 2022:JCO2200032.
https://doi.org/10.1200/JCO.22.00032. Epub ahead of
print. PMID: 35483010
PelvEx Collaborative. Surgical and survival outcomes
following pelvic exenteration for locally advanced
primary rectal cancer: results from an international
collaboration. Ann Surg. 2019;269(2):315–21. https://
doi.org/10.1097/SLA.0000000000002528. PMID:
28938268
Some patients with advanced rectal cancer who had
complete response to chemoradiotherapy can be
successfully managed by watch and wait strategy with
a 3-year disease-free survival similar to those who
underwent resection
Major complications are common after exenteration,
however for patients who achieve an R0 resection,
survival is still quite good. The median overall survival
following R0, R1, and R2 resection was 43, 21, and
10months (P<0.001) with a 3-year survival of 56.4%,
29.6%, and 8.1%, respectively (P<0.001)
262
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H. Hakmi et al.
Rectal prolapse
Pathophysiology Weak pelvic oor, redundant sigmoid colon, patulous anus, deep cul-de-sac
Risk factors Female, multiparity, chronic constipation, long time on toilet, concomitant bladder or uterine
prolapse
Presentation,
diagnosis, and
workup
Management • Can reduce manually, osmotic material (sugar) can be used to reduce prolapse, general
Key steps to
repair rectal
prolapse
Complications
and redo surgery
• Protruding± reducible mass during defecation
• Differentiate from hemorrhoids: Prolapse has concentric circular folds
• Further workup possible if associated with bladder or uterine prolapse
anesthesia+nerve block to relax sphincter
• Emergent surgery if irreducible or ischemic
• Abdominal surgery has lower prolapse recurrence than perineal surgery
• Perineal surgery in elderly patients unt for general anesthesia
• abdominal surgeries:
– Rectopexy±sigmoid resection: Pexy with sutures or mesh and sigmoid resection if
redundant
– Ventral mesh rectopexy: Placement of long mesh (15cm) anterior to rectum, then xed
to sacral promontory
• Perineal procedures:
– Altemeier (perineal rectosigmoidectomy) and Delorme (mucosal stripping and muscle
plication)
• Altemeier and Delorme procedures contraindicated as redo procedure if sigmoidectomy with
rectopexy was performed initially Could jeopardize anastomosis blood supply
• Constipation most common complication due to extensive mobilization or tight rectopexy or
mesh placement
Research about rectal prolapse
Reference Findings
Senapati A, PROSPER Collaborative Group. PROSPER: a
randomised comparison of surgical treatments for rectal
prolapse. Colorectal Dis. 2013;15(7):858–68. https://doi.
org/10.1111/codi.12177. PMID: 23461778
Randomized patients to abdominal or perineal
procedures. Recurrence rates were higher in
perineal approach than anticipated, but not
signicantly different in any comparison
Cavallaro PM, New England Society of Colorectal Surgery
and the Pelvic Floor Disorders Consortium Rectal Prolapse
Quality Incentive Workgroup Participants. Preliminary
report from the pelvic oor disorders consortium: large-scale
data collection through quality improvement initiatives to
provide data on functional outcomes after rectal prolapse
repair. Dis Colon Rectum. 2021;64(8):986–94. https://doi.
org/10.1097/DCR.0000000000001962. PMID: 33951690
All patients undergoing perineal versus
intra-abdominal surgery for repair of rectal
prolapse had improved functional outcomes
8 Colon
Fecal incontinence
Presentation Can be incontinence to stool, but more commonly is incontinence to atus
Pathophysiology Low rectal resections, obstetric traumas, other perineal trauma (e.g., blast injuries), and rectal
inammation
Workup MRI defecography, anal manometry
Treatment Non-operative: With stool bulking agents, timed enemas, bile acid resins, stopping diarrheal
medications, and biofeedback physical therapy
Operative: (only if medical management fails): Sacral S3 neurostimulator, consider
overlapping sphincteroplasty in cases of recent sphincter injuries (obstetric or other direct
trauma to sphincter)
Sacral neuromodulation has better long-term control than sphincteroplasty
Anal Fissure
Anal ssure
Denition Tear in the anal canal lining, usually from hard stool and high resting tone
Presentation Pronounced anal pain. Less commonly with bleeding, voluntary constipation due to pain
Diagnosis Typical ssures: Likely in posterior (most common) or anterior (females) midline,
Atypical ssures: Can occur in malignancy, HIV, and Crohn’s. Likely off midline or
multiple
263
Management Non-op: 50% will recover with sitz bath, stool bulking agents, topical calcium channel
blockers or nitrates (nitrates can cause headaches)
Operative: Reserved for chronic ssure after failure of medical management. Botox
chemodenervation or lateral internal sphincterotomy (LIS)
Anorectal Abscess andFistulae
Anorectal abscess, stulae and proctitis
Pathophysiology Abscess: Blockage of anal crypts at dentate line causing abscess formation. Rectal exam
important to assess deep abscesses
Fistula: Tract forms in the direction of least resistance➔new opening➔epithelialization
Other causes: Hidradenitis, Crohn’s, malignancy, trauma, hidradenitis
Presentation/
diagnosis
Goodsall’s rule
(60% accurate)
Abscess: Firm, tender, uctuant (if supercial)±spontaneous drainage. Dull low back pain
with urinary dysfunction in cases of levator abscess. Supra-levator present with pelvic pain
and diagnosed by imaging
Fistula: Non healing/recurrent abscesses. Purulent or sanguineous drainage. Can identify
external and internal opening
Fistulas with opening anterior to anus usually run in a radial fashion versus stulas with
opening posterior to anus, which usually track in a curvilinear fashion toward the posterior
midline
264
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H. Hakmi et al.
Anorectal abscess, stulae and proctitis
Classication • Abscess: (1) perianal, under skin, does not involve sphincters; (2) ischiorectal: Bounded by
external anal sphincter and ischium; (3) Intersphincteric: Between internal and external anal
sphincters; (4) Supralevator: Above the levator ani muscles; (5) horse-shoe abscess: Extends
to both right and left sides, surrounding anus with connection posterior
• Fistulas: (1) supercial, does not involve sphincter or only a minimal portion and opening is
below the dentate line; (2) Intersphincteric, in between internal and external sphincters; (3)
Transsphincteric involves both internal and external sphincters below the levators; (4)
Suprasphincteric, internal opening at the dentate, with a tract extending above the sphincters
and extending through levator ani; (5) Extrasphincteric, internal opening above the dentate,
with a tract through the levators
Treatment options • Incision and drainage of ischiorectal and perianal abscesses externally closest to anus.
Intersphincteric abscess should be drained through the anus to prevent stula formation.
Supra-levator can be drained by opening the tract though the dentate line
• Horse shoe abscesses should have drainage of both sides as well as posterior midline
• Antibiotics not routinely indicated after drainage. Reserved for immunocompromised
patients or those with signs of systemic infection, or cellulitis
• Fistulotomy in non-complex stulas (supercial, intersphincteric, and low transsphincteric).
Avoid in patients with fecal incontinence and females with anterior stulas (higher
incontinence rate)
• Fibrin glue-seton -LIFT (ligation of inter-sphincteric stula tract- endorectal advancement
ap.-stool diversion using an ostomy in severe cases
• Crohn’s disease: Avoid stulotomy. Use draining setons. Treat with TNF-α inhibitors
Key steps • Fistulotomy: Probe opening to nd external and internal openings. Methylene blue or
hydrogen peroxide can be used to nd opening. Open up the stula tract only after palpating
the thickness of the muscle to be divided
• Advancement ap: Excise external stulous tract➔advancement of V ap of rectal
musularis and mucosa to cover internal opening
• LIFT: Probe tract➔incision in intersphincteric space➔localizes stulous tract in
space➔double ligate and divide➔close internal opening and curette external opening
Complications Abscess: Urinary retention; bleeding; incomplete drainage; pelvic sepsis
• Fistulotomy: Most common is urinary retention➔bleeding; most signicant is fecal
incontinence
Sexually
transmitted
infectious proctitis
• Rectal pain, tenesmus, mucopurulent discharge, ulceration. Most likely gonorrhea and
chlamydia➔syphilis, herpes, chancroid
• Culture, empiric antibiotics and treatment/testing of sexual partners
ator
Intersphincter
fistula
fistula
fistula
fistula
fistula
Exter
l
8 Colon
Ischeorectal
265
Supralev
Levator ani
ic
Perianal
muscle
Puborectalis
muscle
Internal anal
sphincter
nal anal
sphincter
Internal anal
sphincter
External ana
sphincter
Extrasphincteric
Transphincter ic
Superficial
Intersphincteric
Suprasphincteric
Research about anal stulas
Reference Findings
Wasmann KA, etal. Treatment of perianal stulas
in Crohn’s disease, seton versus anti-TNF versus
surgical closure following anti-TNF [PISA]: a
randomised controlled trial. J Crohns Colitis.
2020;14(8):1049–56. https://doi.org/10.1093/
ecco- jcc/jjaa004. PMID: 31919501; PMCID:
PMC7476637
Compared treatment of high anal stula in patients with
Crohn’s disease; chronic seton versus anti-TNF therapy
alone versus surgical closure. Seton treatment was
associated with the highest re-intervention rate, but no
substantial differences in perianal disease activity and
quality of life between the three treatment groups
Hemorrhoids
Hemorrhoids
Anatomy Due to venous congestion of submucosal vascular plexus and weak longitudinal muscles
Internal hemorrhoids above dentate line
External hemorrhoids below the dentate line
Classication of
internal
hemorrhoids
Grade 1: Do no prolapse, Grade 2: Prolapse but reduce spontaneously, Grade 3: Require
manual reduction after prolapse, Grade 4: Cannot be manually reduced
Diagnosis External hemorrhoids present with pain or bleeding. Exam shows engorged external
hemorrhoids. Acute thrombosis can be painful
Internal hemorrhoids are usually painless but present with bleeding (spots on tissue paper or
fresh red blood with bowel movements) or prolapse. Can be painful if strangulated (emergent
case)
Management
External thrombosis: If presenting within 72h➔incision and drainage of hemorrhoidal
clot. If >72h, can treat non operatively with sitz bath, high ber diet, adequate hydration, and
stool softeners
Internal: Non-op initially in non-acute setting with stool softeners, high ber diet and
hydration, avoidance of straining. If fails (continuous bleeding)➔surgery depending on
grade. Grade 1–2 can be treated with band ligation (ofce based). Grade 3–4 and strangulated
are best treated with hemorrhoidectomy
266
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Hemorrhoids
H. Hakmi et al.
Key steps of
procedures:
Complications of
hemorrhoidectomy
and their
management
Banding: Place band above dentate line. If multiple hemorrhoids, best to treat in stages
Hemorrhoidectomy: Suture ligate hemorrhoidal pedicle➔dissect off hemorrhoidal
cushion➔excise
• Pelvic sepsis (urinary retention, fevers, increasing pelvic pain)
• Post ligation bleeding days 5–7 is an expected normal nding and not a complication as
hemorrhoids slough at that time
• Anal stenosis (avoid by leaving intact mucosal bridges between excised hemorrhoids).
-urinary retention-bleeding
Research about hemorrhoidectomy
Reference Findings
Nienhuijs SW, de Hingh IH.Pain after conventional
versus Ligasure haemorrhoidectomy. A meta-analysis. Int
J Surg. 2010;8(4):269–73. https://doi.org/10.1016/j.
ijsu.2010.04.001. Epub 2010 Apr 11. PMID: 20388563
Anal Cancer
Ligasure use for hemorrhoidectomy has lower
immediate post-operative pain in comparison to
conventional hemorrhoidectomy with similar rates
of post-operative complications
Anal dysplasia (AIN: anal intra-epithelial neoplasia)
Pathophysiology • Related to HPV infection. Subtypes 6&11 likely to cause benign disease versus 16&18 with
malignant potential.
• Does not require anal intercourse.
• HIV and chronic immunosuppression➔high risk of anal dysplasia
Prevention Vaccination effective at young age before sexual activity
Classication Grades I and II are low grade AIN versus grade III is high grade AIN
Diagnosis and
treatment
• Diagnosis by PAP smear or tissue biopsy after application of acetic acid
• Benign condylomas can be observed➔spontaneous regression, if no regression, extensive
or >1cm➔topical therapy in the ofce (imoquimoid and 5-FU) versus topical therapy at
home (higher recurrence). If too extensive for topical therapy➔surgical excision
(epidermis and dermis only) and fulguration
• Home topical therapy can only be used for external lesions, not for internal anal lesions
• Low grade AIN can be observed versus high grade should be treated with topical therapy
8 Colon
Anal cancer
Types • Upper anal cancer: Adenocarcinoma; mid anus (transition zone above the dentate line):
Adenocarcinoma, melanoma, and squamous cell carcinoma (SCC); lower anus: SCC or
melanoma
• Pagets disease of the anus: Primary with anorectal adenocarcinoma or secondary with
metachronous GI versus tubo- ovarian adenocarcinoma
Presentation • Mass, bleeding, itching
• Pagets: Pruritis, red or hypo-pigmented crusted lesions
267
Workup Digital rectal exam, and inguinal nodal exam
Treatment • Chemotherapy with mitomycin and 5-FU and radiation. Follow-up 12weeks after completion of
Follow-up Anoscopy and inguinal lymphatics exam every 6months for 5years
Anoscopy, colonoscopy, MRI of the pelvis and CT chest/abdomen/pelvis for metastasis
treatment as it can take up to 6months for complete remission to occur
• If tumor persistence 12weeks after completing radiation, patient will require surgical resection,
typically APR
Research about anal dysplasia and cancer
Reference Findings
Machalek DA; SPANC Study Team. The Study of the
Prevention of Anal Cancer (SPANC): design and
methods of a three-year prospective cohort study. BMC
Public Health. 2013;13:946. https://doi.
org/10.1186/1471- 2458- 13- 946. PMID: 24107134;
PMCID: PMC3852594
Palefsky JM,; ANCHOR Investigators Group.
Treatment of anal high-grade squamous intraepithelial
lesions to prevent anal cancer. N Engl J Med.
2022;386(24):2273–82. https://doi.org/10.1056/
NEJMoa2201048. PMID: 35704479
HSIL was monitored and in those patients anal cancer
progression developed in 0.2% per year
Surgical treatment of HSIL rather than observation was
associated with reducing cancer progression in patients
with HIV
Bentzen AG, Guren MG, Wanderås EH, Frykholm G,
Tveit KM, Wilsgaard T, Dahl O, Balteskard
L.Chemoradiotherapy of anal carcinoma: survival and
recurrence in an unselected national cohort. Int J
Radiat Oncol Biol Phys. 2012;83(2):e173–80. https://
doi.org/10.1016/j.ijrobp.2011.12.062. Epub 2012 Mar
19. PMID: 22436791
Complete response after CRT was obtained in 87% of
patients with nonmetastatic squamous cell carcinoma
of the anal region. Response rising up to 93% after
salvage surgery
The 3- and 5-year overall survival were 79% and 66%
Endoscopy
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JereySilverstein, EricBallecer, UmairNasir,
andJamesGrendell
Esophagogastroduodenoscopy
Indications Contraindications
9
Dyspepsia with alarm symptoms or age>45 or unresponsive to
therapy
Dysphagia/odynophagia
New onset GERD in older adults
Persistent vomiting of unknown cause
FAP
Abnormal UGI tract X-ray
GI bleeding
Iron-deciency anemia (normal colonoscopy)
Portal HTN: Document or treat esophageal varices
Abnormal radiologic ndings
Screening for Barrett’s esophagus for patients with multiple risk
factors
J. Silverstein (*)
Department of Surgery, NYU Long Island School of
Medicine, Mineola, NY, USA
E. Ballecer · U. Nasir
Department of Gastroenterology, NYU Long Island
School of Medicine, NYU Langone—Long Island
Hospital, Mineola, NY, USA
e-mail: umair.nasir@nyulangone.org
J. Grendell
Division of Gastroenterology, Hepatology and
Nutrition, NYU Long Island School of Medicine,
NYU Langone—Long Island Hospital,
Mineola, NY, USA
e-mail: james.grendell@nyulangone.org
Patient unable to tolerate sedation
Hemodynamically unstable patients
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Ajouz et al. (eds.), The ABSITE Blueprints, https://doi.org/10.1007/978-3-031-32643-1_9
269
270
Surveillance
Surveillance
Condition Surveillance
Familial adenomatous polyposis 1–5years starting at age 20–25
Barrett’s esophagus Non-neoplastic metaplasia: 3years
Low-grade intestinal metaplasia: 6–12months
J. Silverstein et al.
Esophageal varices following sclerotherapy and
banding
Gastric ulcer Every 6weeks until healed with biopsy and brushings
Esophageal ulcer Every 6weeks until healed with biopsy and brushings
ASGE guidelines➔do not recommend screening for diagnoses of gastric atrophy, including intestinal metaplasia
without dysplasia, treated achalasia, or a history of gastrectomy
• Patients with pernicious anemia should have a single endoscopy with no follow-up
Every 6–8weeks, until all varices are obliterated, then yearly
Preoperative Consideration
Preoperative considerations
Lying down on their left side
Positioning
Anesthesia
Right side is down➔for an acute UGI bleed (blood will pool in the fundus and may
hide a Dieulafoy lesion in the fundus)
• Some patients may not need sedation if using small-diameter endoscopes (<6mm)
• Topical anesthesia in the form of sprays may be used to improve tolerance
• Indications for sedation➔moderate level adequate for most diagnostic and
uncomplicated therapeutic interventions in the majority of patients
Indications for general anesthesia➔patients with increased risk for aspiration, difcult
airway management, or increased cardiopulmonary complications of endoscopy
Throughout the procedure➔practice principles of safe sedation (continuous pulse
oximetry and ECG monitoring)
Antibiotics Because the risk of infection related to routine diagnostic upper endoscopy is
low➔antibiotic prophylaxis is not recommended
Key Steps forEGD
Management of foreign bodies
Case Management
Object >6cm long or>2cm wide Endoscopic removal
Coins+symptomatic patient Urgent removal
9 Endoscopy
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Management of foreign bodies
Case Management
Coin ingested+asymptomatic patient Endoscopic retrieval if object remain >3–4weeks
Sharp, pointed object Urgent endoscopic removal
>2 magnets Emergency endoscopic removal
Children who present >12h after ingestion are more susceptible to
perforation and stula (ulceration of the gastric mucosa can occur
in less than 8h)
Button battery ingestion+symptomatic Emergency endoscopic retrieval
271
Button battery+asymptomatic+child
<5years+battery ≥20mm in diameter
Button battery+asymptomatic+child
>5years+battery ≥20mm in diameter
Button battery+asymptomatic
patient+button battery retained in
stomach after 10–14days+battery
<20mm
Any foreign body in esophagus >24h Endoscopy under GA+surgical consultation
Urgent endoscopic retrieval
Serial X-ray at 48h if battery >20mm or 14days if battery ≤20mm
Endoscopic removal
Indications for endoscopy in patients with foreign body ingestion
Esophageal obstruction (evidenced by an inability to handle oral secretions)
Emergent
endoscopy
Urgent
Endoscopy
(within 24h)
Disk batteries in the esophagus
Sharp-pointed objects in the esophagus
Esophageal foreign objects that are not sharp-pointed
Esophageal food impaction without complete obstruction
Sharp-pointed objected in the stomach or duodenum
Objects >6cm in length at or above the proximal duodenum
Magnets within endoscopic reach
Caustic substances
GI bleeding
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